Pre-Claim Review

Despite concerns from the home health industry about the burden of a prior authorization requirement and how it will restrict access to care, CMS will move forward with a three-year Medicare pre-claim review demonstration for home health agencies in five states as published to the rule posted in the Federal Register on June 8, 2016.

The demonstration will begin in Illinois no earlier than Aug. 1, 2016, in Florida no earlier than Oct. 1, 2016, in Texas no earlier than Dec. 1, 2016, and in Michigan and Massachusetts no earlier than Jan. 1, 2017.

Under the demonstration, agencies will be encouraged to submit to their Medicare Administrative Contractor (MAC) a request for pre-claim review along with relevant documentation to support coverage. After receiving all relevant documentation, the MAC will review the agency’s request to determine whether the service level complies with applicable Medicare coverage and clinical documentation requirements.

According to CMS, agencies should submit the Request for Anticipated Payment (RAP) before submitting the pre-claim review request and begin providing services while awaiting the MAC’s decision.

The MAC will provisionally approve or disapprove payment after submission of a request for pre-claim review. For the initial submission of a pre-claim review request, the MAC will make all reasonable efforts to make a determination and issue a notice of the decision within 10 business days.

If the MAC declines payment, the agency may amend the pre-claim review request and resubmit it. Pre-claim review requests may be resubmitted an unlimited number of times.

For subsequent review requests from an agency, CMS or its agents will conduct a complex medical review and make all reasonable efforts to notify the agency of its decision within 20 business days.